As discussed this spring: for this panel, care management stands or falls on two things — patient cost-sharing and staff burden. So this plan prices the first into every figure on the page (cost-sharing exposure and bad debt are already netted out, and the donor-funded coverage your team is exploring only improves on these numbers), and removes the second by design: CoachCare's care team handles roughly 90% of patient interactions and escalations, with only ~10% ever reaching the practice, through the channel your team chooses. CCM first, across the CCM-eligible core of your Medicare panel — the list your team has already identified. RPM stays staged and ready, as the expansion.
The headline counts 742 unique patients in active remote care at Month 24 under Scenario A — a single program, so patients and enrollments are the same number, and no unique count is ever published below the largest program's census. Under Scenario B the same patients would be enrolled with a device paired for those whose conditions warrant it; program enrollments are never labeled “patients.” The 16,090 care hours are delivered by CoachCare's care team — CoachCare's work, not health-center headcount, and never subtracted from practice margin.
In April your team told us exactly what a care-management program has to get right for this panel: two constraints. This entire plan is engineered backwards from them.
One structural point worth naming: in some vendor models, the practice's own staff still end up as first-line triage on every abnormal reading — which quietly converts an outsourced program back into an internal workload. This model is built to be the opposite: triage, outreach, documentation and follow-through sit with CoachCare's care team, governed by the escalation protocol below, and the practice sees only the ~10% that genuinely needs a clinical decision from your side.
Two scenarios, both built on the patient counts your team provided and both fully full-service. Scenario A models exactly what your team asked for — Chronic Care Management only — and it is the plan of record on this page: it drives the headline figures, the dashboard and the calculator below. Scenario B prices the recommended expansion — the same CCM program with remote physiologic monitoring paired for the patients whose conditions warrant a device.
The Medicare panel as your team sized it in April 2026. It squares with the public record: Medicare at ~11.8% of the health center's 27,878-patient CY2024 UDS panel, right in line with the national FQHC share.
The CY2026 FQHC / RHC eligibility row puts 75% of the Medicare panel in the CCM-eligible core — 2,475 of the ~3,300 lives. That lands just below the ~2,700 your team identified in April 2026, so the model is the more conservative of the two counts, and your list corroborates it.
Programs like this typically enroll 25–35% of eligible patients, and up to ~50% with strong provider buy-in. This model sits at 30%, mid-range — and it is ceiling-limited, so stronger buy-in scales every figure up.
Scenario A: full-service delivery, CY2026 national non-facility PFS rates, net of cost-sharing and bad debt.
| 24-Month Outcome | Scenario A — CCM OnlyThe plan of record | Scenario B — CCM + RPMThe recommended expansion |
|---|---|---|
| Net reimbursement | $1,717,534 | $2,857,498 |
| Net to the health center | $724,828 | $1,219,291 |
| Practice margin % of net reimbursement | 42.2% | 42.7% |
| Active program enrollments, Month 24 | 742 | 1,493 |
| Unique patients, Month 24 | 742 | 974 |
| Hospitalizations avoided | 0 | ~94 RPM is the model's only source |
| First net-positive month | Month 2 | Month 2 |
The second billable line a paired device adds, per enrolled patient per month, at national non-facility PFS rates — additive to the CCM line on the same patient.
The CY2026 FQHC / RHC row puts RPM eligibility at 65% of the Medicare panel with 35% acceptance — enough reach to pair a device across essentially the whole enrolled CCM population.
Avoided admissions come from device data alone in this model, so they are a benefit Scenario A cannot produce at all.
A named service line following the Medicare patient between visits — delivered full-service by CoachCare inside the health center's Epic environment, governed by your clinicians. And the timing matters: since January 1, 2026, federally qualified health centers bill the individual care-management codes at national non-facility Physician Fee Schedule rates — each one separately payable on top of the PPS visit.
G0511 — the single bundled care-management code FQHCs billed for years — stopped being payable on September 30, 2025. The bundled era, where doing more care management paid the same as doing less, is over.
Health centers now bill the individual CCM codes — and RPM codes, when monitoring is added — as separate line items at national non-facility Physician Fee Schedule rates.
These are not carve-outs of the PPS rate. Care-management lines sit on top of the health center's encounter revenue — between-visit care stops being an unfunded cost and becomes a billable service.
| Service | Codes | Health-center use |
|---|---|---|
| Scenario A — live at launch | ||
| CCM, clinical staff time | 99490 · 99439 | First 20 minutes / each additional 20 minutes of clinical-staff care management per month — the program's workhorse pair |
| CCM, provider-personal | 99491 · 99437 | Months where the billing practitioner personally furnishes the care-management time |
| Complex CCM | 99487 · 99489 | Months requiring moderate-to-high-complexity medical decision-making and care-plan revision |
| Scenario B — added when RPM is paired | ||
| RPM setup & device supply | 99453 · 99454 | Device provisioning and monthly transmission for the monitored cohort |
| RPM treatment management | 99457 · 99458 | Monthly clinical review, titration support and escalation on device data |
| Short-window RPM (new for CY2026) | 99445 · 99470 | 2–15-day monitoring windows after an acute episode — not included in any modeled figure; upside on top |
Rates are the CY2026 national non-facility Physician Fee Schedule amounts — since January 2026 health centers bill these codes individually at the national amount, with no geographic adjustment to the local MAC locality. Blended net reimbursement per active patient-month, after cost-sharing exposure and bad debt: ~$110.75 CCM; under Scenario B, ~$97.48 RPM. Code-level assumptions are itemized in the companion Value Analysis workbook.
Your team raised Medicare Advantage plan participation as a known headache — past experience taught you that some plans make care management difficult. CoachCare committed to pre-checking the Florida plan list before any patient is enrolled. Here is that pre-check: the plans that actually hold Indian River County's Medicare enrollment, from public CMS enrollment data (July 2026) and each carrier's published provider policy, verified against CoachCare's claims experience at other Florida practices. One rule sits above all of it: no patient is ever enrolled into a denial.
Shares of the county's total Medicare book (MA carrier shares scaled by the county's 43% MA penetration). Within the MA book itself: UnitedHealthcare 39.2% · Humana 28.6% · Florida Blue 8.2% · Aetna 6.7% · others smaller. The health center's own panel is assumed to mirror the county mix — confirmed against the actual roster at implementation.
The ~86% figure is traditional Medicare (~57% of the modeled program) plus the two largest MA carriers (~29%), before the remaining plan confirmations even complete.
Published provider policy reviewed July 2026 for every carrier below; carriers marked “confirmation in progress” carry normal pre-launch diligence items — a policy check or a contract-structure question that typically resolves with one billing-office answer or a plan call — completed before enrollment wave one.
| Plan family | Share of county MA | Pre-check status | Notes |
|---|---|---|---|
| UnitedHealthcare | 39.2% | Verified | Published policy consistent with Medicare's rules for these codes; no restrictions found. The largest carrier in the county. |
| Humana | 28.6% | Verified | Published guidance consistent with Medicare's rules, including its dual-eligible-focused plans. |
| Florida Blue | 8.2% | Confirmation in progress | Published materials do not address these codes either way — being verified directly against Florida claims experience and, where needed, a plan call before any member is enrolled. |
| Aetna / CVS | 6.7% | Verified | Verified for CCM, the launch program. Scenario B device coverage is condition-specific — aligned with the risk-stratified cohort this program enrolls first. |
| Freedom Health | 5.1% | Confirmation in progress | Confirming contract structure with the health center's billing office — one answer resolves it. |
| Ultimate Health Plans | 3.4% | Confirmation in progress | Same contract-structure confirmation — normal pre-launch diligence for smaller delegated plans. |
| Health First | 3.0% | Verified | No restrictions located; standard months-1–3 payment monitoring. |
| Devoted Health | 2.1% | Verified | No restrictions located; standard monitoring. |
| Wellcare (Centene) | 1.5% | Verified | Published policy mirrors Medicare's billing rules. |
Remaining ~1.6% of the MA book is out-of-area plans (seasonal residents), paid under their home plans' rules — monitored, too small to gate launch. Source: CMS Monthly MA Enrollment by State/County/Contract, July 2026 release; carrier provider policies as published July 2026. A federal baseline sits under this table: Medicare Advantage plans are required to cover chronic care management as part of the Medicare Part B benefit — differences between plans are paperwork and payment mechanics, which is exactly the part CoachCare operates.
Every carrier holding county enrollment was checked against its own published provider policies for this program's codes (July 2026). Findings are the table above.
Each plan in the health center's actual panel is checked against real payment behavior from CoachCare's other Florida practices, and months 1–3 run under close payment monitoring — feeding the joint payment-report review in months 4–6.
Any plan with unresolved issues is removed from the eligibility list before enrollment — so the program simply does not enroll members into plans that have not cleared verification. No patient is ever enrolled into a denial.
The health center runs Epic hosted by Health Choice Network — MyChart included. CoachCare integrates with Epic bi-directionally, and the closest analog to HCN's shared, multi-center Epic environment is the OCHIN-model engagement already underway on CoachCare's side. Stated plainly: CoachCare has not yet integrated with an HCN-hosted health center — which is why HCN is pulled into integration scoping from the first conversation, not after contracting.
Bi-directional enrollment flags and trigger ordering by service mean providers refer from inside Epic, and enrollment status is visible in the chart in real time — no side system to check.
When monitoring data flows (Scenario B), remote readings land in a dedicated flowsheet, kept apart from clinic-measured vitals. That separation is a quality-reporting feature: home blood-pressure series stay clean, attributable and usable — without contaminating the office record.
The CoachCare billing engine auto-generates the claim for every eligible patient, every month. The health center's billing team receives a monthly reconciliation file — a check step, not a build step.
The first question any clinical leader asks about an outsourced program is the right one: when a patient reports something abnormal, who handles it — and how do we know? The answer is a documented protocol, not ad hoc judgment. Every clinical interaction in the CCM program — and every device reading, when RPM is paired — runs through one escalation engine, governed by CoachCare's Care Management Standard Operating Procedures. This is the operational machinery behind the ~90/10 split: disciplined routing is what keeps the practice's share at 10%.
CCM check-ins and RPM readings run the same decision logic, so escalations are consistent rather than subjective — and a critical value escalates regardless of symptoms.
A vital or a symptom report arrives — a blood-pressure, weight or glucose reading from a cellular device, or something a patient tells the care team on a monthly CCM call.
A critical value escalates regardless of symptoms. An out-of-range value first gets a retake plus a symptom check before anything reaches the health center.
A trend is defined objectively — 3 consecutive out-of-range readings at least 1 hour apart (blood pressure / glucose), or 3 readings within 7 days (heart rate) — never a single stray number.
If the patient cannot be reached, the care team leaves a voicemail with a callback line and still escalates a critical value or an out-of-range trend. Every escalation documents the vital, findings, method, contact, outcome and follow-up.
Any of these, reported live during outreach, moves straight to the emergency pathway:
For a safety-net panel with transportation and phone-continuity barriers, this is the guarantee that matters most: the emergency response never waits on a callback.
Clinical changes split three ways — so physicians are never paged for what does not need them.
Active emergent symptoms follow the emergency pathway immediately — the practice is informed, but the response never waits on it.
A non-critical clinical change is routed to a defined member of the health center's care team, through the channel your team chooses — the right person, not a broadcast page.
A stable or resolved item is documented as an FYI in the record — visible for continuity, without interrupting anyone. This lane is most of the 90%.
Any emergency-department visit or hospitalization in the last 60 days triggers a fixed three-touch sequence. It is the concrete readmission-prevention loop behind Scenario B's hospitalizations-avoided figure — and a direct contribution to the utilization measures the health center's ACO participation rewards. Each touch documents and escalates per protocol.
Identify precipitating factors, reconcile medications, confirm a primary-care or specialist follow-up within 7–14 days, and assess symptoms.
Verify medication adherence, re-evaluate triggers, confirm the follow-up appointment actually happened, and verify labs.
Review medications and risk, review the outcomes of the completed visit, and re-assess symptoms.
A 24-month forecast of the plan of record: CCM only, on the 2,475-patient CCM-eligible core of the ~3,300-life Medicare panel (75% of it, per the CY2026 FQHC / RHC eligibility row — slightly below the ~2,700 your team identified), referred by 14 adult-medicine providers, enrolled by a dedicated outreach team including a CoachCare-funded on-site enrollment specialist, at 30% acceptance, CY2026 national non-facility PFS rates, net of cost-sharing and bad debt, ~1.5% monthly attrition. Shared-savings performance and the donor-funded cost-sharing idea are not in these numbers — both are upside on top.
| Scenario A — CCM only | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| Net reimbursement | $730,749 | $986,785 | $1,717,534 |
| Total CoachCare fees (incl. one-time) | $430,566 | $562,141 | $992,707 |
| Net to the health center (after all fees) | $300,183 | $424,644 | $724,828 |
| Delivered full-service — outreach, enrollment, monthly care delivery, escalation management, documentation and billing handled by CoachCare; no new health-center headcount required. | |||
Net to the health center is stated after all CoachCare fees: $965,988 of CCM program fees plus $26,719 of ancillary cost covering one-time implementation, integration setup and a per-patient-month component. The on-site enrollment specialist is staffed at CoachCare's expense — embedded value, never subtracted from practice margin. Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume — auto-generated, with the billing team working a monthly reconciliation file rather than building claims.
≈7.7 FTE-equivalent of outreach, monthly care delivery, documentation and escalation handling — CoachCare's work, not center headcount, at 45–60 delivered minutes per patient per month.
The modeled monthly net to the health center once the census holds its ceiling — recurring, diversified, additive to PPS encounter revenue.
At the modeled defaults the explorer reproduces the Scenario A workbook run exactly: M24 census 742, $1,717,534 of 24-month net reimbursement, and $724,828 net to the health center. RPM economics are deliberately excluded here — they belong to Scenario B, priced separately in the comparison above.
The health center already answers for quality in two places at once — the UDS clinical measures reported to HRSA every year, and the Medicare Shared Savings Program through Health Choice Care, LLC, the all-health-center ACO organized through Health Choice Network. We did the homework on that ACO before writing this page. What we found is a genuinely strong record, a few facts worth confirming together, and a program that helps under every possible answer.
ACO-level figures from CMS Shared Savings Program public performance files through PY2024 (as of July 2026) and the ACO's own public reporting. Center-level allocations are not public — see the discovery agenda below.
None of these change what the program earns on fee-for-service rails; all of them sharpen what it contributes beyond that. They are exactly the questions the clinical working session with CoachCare's CMO is designed to put on the table — with the ACO's reporting in front of us rather than guessed at.
However the risk question resolves, the mechanics below hold — the program pays on fee-for-service rails today and contributes to ACO performance regardless.
Care-management codes count toward Medicare's patient-assignment methodology, and services on a health-center claim count as primary care for assignment purposes (CMS assignment specifications). Monthly CCM billing adds recurring primary-care weight to the health center's own claims — deepening and defending the attributed lives every ACO dollar is computed on.
The ACO's quality set centers on blood-pressure control, glycemic control, depression screening and admissions in multi-chronic patients — nearly a care-management scorecard. Public CMS reporting shows blood-pressure control has been the ACO's softest measure (70.6% in PY2022 against a 76.2% all-ACO average, improved to 77.0% by PY2024) — the precise measure device-based monitoring moves fastest under Scenario B.
For traditional-Medicare patients attributed to the ACO, every avoided hospitalization reduces performance-year expenditures — the line shared savings is earned on. Any avoided admissions produced once RPM is paired under Scenario B would accrue to that performance on top of the fee-for-service revenue the health center bills for the same patients.
Independent of the ACO question, the day-to-day quality work runs like this.
The care team works the health center's care-gap lists inside its monthly outreach — screenings due, labs outstanding, visits overdue — and reports closure activity back monthly, per provider.
Care pathways per condition — hypertension, diabetes, heart failure, kidney disease — so monthly contact follows a clinical protocol tuned to the panel your teams already prioritize, not a generic script.
Transportation, food, housing and program-navigation resources are part of the care team's toolkit — consistent with the health center's HRSA-recognized social-risk work, and documented in the record.
Home blood-pressure series (Scenario B) land in a dedicated flowsheet, separate from office vitals — clean, attributable data the quality team can actually use for reporting on control measures.
Programs live or die on two curves: how many eligible patients say yes, and how long they stay. Here is what a program like this typically does — and what this model assumes, which is deliberately more conservative.
The range programs like this typically achieve — rising to ~50% with strong provider buy-in, because a provider's recommendation is the single biggest driver of a patient's yes.
Acceptance is modeled mid-range, not at the optimistic end. Because the forecast is ceiling-limited, every point of acceptance above 30% scales the results — try it in the Scenario Explorer.
Attrition runs ~1.5% per month, concentrated early; enrollment normalizes around month 6, and patients who pass their first three months typically stay about eighteen.
The proposed next step is a working session, not a contract: your clinical leadership and CoachCare's Chief Medical Officer walk the care model, the escalation protocol and the care-team workflow in detail. From there, implementation runs 60–90 days depending on integration scoping with Health Choice Network, and the first months of billing are reviewed collaboratively, payment report by payment report.
Your clinical and quality leadership with CoachCare's Chief Medical Officer: care pathways by diagnosis, the escalation protocol, care-team pod structure, and how the ~90/10 split works in practice. Decisions on preferred escalation channels and eligibility criteria start here.
Integration scoping with Health Choice Network and the health center's IT leadership; protocol sign-off; the risk-stratified eligibility list built from the ~2,700; co-branded materials, caller ID and voicemail scripts prepared; billing configuration and reconciliation workflow agreed.
The dedicated outreach team begins provider-referral and telephonic enrollment; care-team pods pick up each patient's monthly cadence as they join. The modeled census reaches its 742-patient ceiling around month 7 — and the model turns net-positive in month 2.
Payment reports reviewed together, line by line: enrollment versus billed versus paid, plan-level behavior checked against the pre-launch Medicare Advantage review, and any consistently problematic plan removed from eligibility. The program settles into its steady monthly rhythm — and the Scenario B decision can be revisited with real data.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 conditions managed for 500,000+ patients.
Providers running remote care programs day to day.
Remote care programs launched on this infrastructure.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions delivered.
CMS's CY2027 Physician Fee Schedule proposed rule, published July 16, 2026, proposes to reprice remote physiologic monitoring. Here is what it reaches, what it leaves alone, and how the operating model behind this service line absorbs it.
CMS's remote-monitoring proposals sit in one code family: RPM. CCM, PCM, and TCM are not part of them. This forecast does not model RPM at all — all $1,717,534 of it is CCM. The proposed repricing does not reach this service line.
The delivery model has more than one shape, and CoachCare is preparing each so the service line's economics hold wherever the rule settles. One unbundles the program into its parts — SaaS platform, device logistics, and program enablement — priced as components. Another engages CoachCare to run the staffing itself, an MSO-style arrangement in which the practice owns the clinical program and the billing while CoachCare carries the labor model. Neither requires re-architecting the service line described on this page.
Alongside the fee schedule, CMS's ACCESS Model pays remote care as a risk-based per-member-per-month arrangement rather than per code: recurring per-beneficiary payments, half of each one withheld and reconciled against outcome attainment. Cardiometabolic care is among its four clinical tracks. What earns under that structure — controlled pressures, titrated therapy, decompensations caught early — is what this service line is built to produce.
This forecast repriced code by code at CMS's CY2027 proposed values, at this practice's own MAC locality. The movement shown is the ordinary annual conversion-factor and RVU update that happens every year — not the remote-monitoring repricing, which does not reach these codes.
All $1,717,534 of this 24-month forecast is CCM. The remote-monitoring proposals reach the RPM code family only, so none of the proposed repricing applies to it. Repriced at CY2027 proposed values the forecast moves 2.4% — ordinary annual movement in the conversion factor, the same order as any other year.
CY2026 versus CMS's published CY2027 proposed values, shown at national non-facility amounts so they can be read against CMS's own tables. This practice's locality-adjusted amounts differ; the repricing above uses the local figures.
| Code family | What CMS proposed | CY2026 | CY2027 proposed | Change |
|---|---|---|---|---|
| Not in scope — the codes the proposal does not reach | ||||
| 99490 / 99439 / 99491 · CCM | No structural change proposed | $66.13 | $64.04 | −3% |
| 99495 / 99496 · TCM | Not addressed by the proposal | Outside the remote-monitoring provisions entirely | ||
National non-facility amounts; CY2027 values are CMS's own published proposals in Addendum B of CMS-1848-P. The care-management rows show the lead code in each family; every code in those families moves within about 4% in either direction, which is ordinary annual movement rather than a repricing. The RPM reductions are also phased — section 1848(c)(7) of the Act caps any one code's total-RVU reduction at 19% in a single year, and CMS publishes the affected codes, so CY2027 is a single-digit year for a typical program and the remainder arrives no earlier than CY2028.
Six reasons this fits Treasure Coast Community Health specifically, not remote care in general.
Individual care-management codes on the health-center claim, in addition to the PPS encounter, filed by the health center's own reimbursement team. The CY2026 move to code-by-code billing on top of the encounter is the reason the forecast on this page exists, and the program is built around it.
Enrollment outreach, the care team, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. The care team handles roughly 90% of patient interactions and escalations, with only about 10% ever reaching the practice, at a 42.7% margin, and cost-sharing exposure and bad debt are already netted out of that figure.
The health center already answers for quality through its ACO. This plan adds cellular devices, documented monthly clinical management and Medicare billing to the between-visit work the clinicians already do, and sets a working rule for how the programs share a patient. Where the care team stands today is the first discovery question.
CoachCare integrates with Epic, alongside the Health Choice Network environment the health center runs on, so referral orders leave the chart and vitals, documentation, enrollment status and billing-ready claims come back into it. One record for clinicians, one workflow for the reimbursement team, no second system.
For QMB and dually eligible members the coinsurance objection disappears, and the top APCM tier is priced for this population. The Medicare Advantage share, led by UnitedHealthcare and Humana, is handled plan by plan up front, and the Medicaid crossover is handled on the claim so nothing is billed to a patient who cannot be billed.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. If the census does not build, CoachCare does not get paid, which is why the plan is priced against the two constraints your team named before it goes to paper. The forecast, Disclosures and workbook behind this page are yours to keep either way.